Awareness of stroke among patients with chronic kidney disease on hemodialysis: a cross-sectional study

ABSTRACT BACKGROUND: Stroke is a major cause of mortality worldwide. Renal dysfunction is an important risk factor for stroke. Brazilian studies on stroke knowledge are generally population based. Studies stratifying stroke knowledge according to comorbidities are rare. Scientific data are essential to guide the awareness of stroke. OBJECTIVE: To assess stroke knowledge in patients with chronic kidney disease (CKD) on hemodialysis. DESIGN AND SETTING: Cross-sectional analytical study of patients with CKD on hemodialysis in north-eastern Brazil. METHODS: A self-administered questionnaire survey on stroke awareness was administered to patients with CKD on hemodialysis between April and November 2022. The chi-square test and other descriptive statistics were used. Univariate and multivariate analyses were performed using logistic regression. RESULTS: A total of 197 patients were included in the analysis. The Brazilian acronym for stroke was used by 53.5% of the participants. Less than 10.0% of the sample showed optimal decision-making ability regarding stroke. Of the participants, 29.9% knew at least one risk factor and one symptom; however, this was considered as having below the minimum capacity because they did not know the emergency service call number. In the analysis adjusted for income and education, females (odds ratio [OR], 0.40%; 95% confidence interval [CI], 0.20-0.82), older patients (OR, 0.24%; 95% CI, 0.09-0.63) and having at most one comorbidity (OR, 0.48%; 95% CI, 0.23-0.98) were factors for lower levels of knowledge or ideal decision-making capacity against stroke. CONCLUSIONS: Patients on hemodialysis, especially women and older people, have little knowledge about stroke.

In Brazil, knowledge about stroke in the general population is low, [8][9][10] and it is believed that this is also true in the CKD population. It is also noteworthy that failure to recognize these signs and symptoms delays seeking medical care, which negatively affects poststroke treatment and reduces the likelihood of recovery. 11

OBJECTIVE
This study aimed to determine the level of knowledge about stroke in a population with CKD at a dialysis center in northeastern Brazil. Consequently, we investigated the ability of the study population to recognize a stroke and the correct triggering of emergency services.

Study design and population
This was a cross-sectional analytical study conducted in a dialysis center located in the city of Juazeiro, state of Bahia, Brazil, following the recommendations of the statement Strengthening the Reporting of Observational Studies in Epidemiology. 12 In this study, data were collected between April and November 2022.
The study included patients with CKD on hemodialysis who voluntarily agreed to participate in the research and answer the data collection instrument using a semi-structured questionnaire (Attachment 1). The following inclusion criteria were established: (1) age of ≥ 18 years, (2) have been on treatment for > 3 months, and (3) no known history of cognitive impairment. Those who did not complete the questionnaire were excluded.

Variables
The questionnaire used in the study had already been used in another study with a different population. 10 It was based on a literature search that included other studies that also examined the level of knowledge about stroke in their respective target populations. 8,9 Each participant was asked to answer sociodemographic questions that included information about sex, age, family income, and education, as well as questions about stroke knowledge. In addition, the history of comorbidities reported by each participant was examined.
The stroke questionnaire consisted of four questions: (1) Do you know what a stroke is? (2) Can you name at least three signs or symptoms of stroke? (3) Can you identify at least three risk factors for stroke? (4) What is the phone number of the emergency medical service in Brazil?

Level of knowledge about stroke
In this study, stroke knowledge was assessed based on the ability to make decisions when faced with a stroke. This decision-making was categorized into three levels: (1) ideal (able to recognize three symptoms and three risk factors and know how to call the emergency medical service), (2) minimum required (able to recognize one symptom and one risk factor and know how to call the emergency medical service), and (3) below minimum (none of the aforementioned characteristics met).

Sample size and statistical analysis
A total of 443 patients were registered at the dialysis center.
A minimum sample size of 192 participants was sufficient to achieve a precision of 10% around our estimate of stroke knowledge of 43.9% 8 with a confidence level of 99.9% assuming a nonresponse rate of 15%.

RESULTS
The study sample comprised of 197 participants. Of these, 106 (53.8%) were men. The mean age (± SD) was 50.77 (± 16.97) years. A total of 105 participants (53.5%) recognized the Brazilian acronym for cerebrovascular accidents. The sociodemographic profile of the sample and prevalence of each response to stroke knowledge are presented in Table 1.
The decision-making capacities of patients with stroke are shown in Figure 1. In the population studied, most of the participants presented knowledge below the minimum, according to the established criteria. Less than 10.0% of the sample had an ideal decision-making capacity. It is noteworthy that 29.9% of the participants knew at least one risk factor and one symptom; however, this knowledge was classified as below the minimum because they did not know the emergency service call number.
In the unadjusted investigation, women had an OR of 0.49 (95% CI, 0.25-0.95) for minimal or ideal knowledge of stroke compared with the reference (men) in the logistic regression ( Table 2).
In addition, the age of ≥ 60 years had an OR of 0.33 (95% CI, 0.14-0.83) for minimal or ideal knowledge about stroke compared with the age group between 18 and 39 years ( Table 2).
Moreover, in the analysis adjusted for income and education, it was found that in addition to female sex and the age of > 60 years, having at most one comorbidity was associated with having a less minimal or ideal capacity to cope with a stroke.

DISCUSSION
Our results show that in the population with CKD on hemodialysis, knowledge about stroke is generally below the minimum.
This low level of knowledge about the recognition of stroke, in both quantitative and qualitative terms, is also considered insufficient by the general population in Brazil 8-10 and some other countries. [13][14][15] In a cross-sectional study conducted between 2011 and 2012 in Poland with a sample of 1,134 participants, more than 40% of the study population could not identify any stroke symptoms, and less than 40% were able to identify at least two risk factors for stroke. 15 Importantly, our results may have been influenced by the socioeconomic profile of the sample. Most participants had a family income of less than $200.00, and only 5.1% had completed a college education. These results could be related to the fact that the study was conducted in Northeast of Brazil, which is characterized by large socioeconomic differences from other regions of the country. Many cities in this region are characterized by a low Human Development Index (HDI) and high indicators of illiteracy, infant mortality, and poverty. 16 In similar studies conducted in the southeastern region of Brazil, a region with a higher HDI and lower poverty index than the region in which this study was conducted, researchers also found that the samples' knowledge of stroke was low. 8,9 Nevertheless, in the sample by Gomes et al.,35.0% knew at least three risk factors for stroke, 17.9% could name at least three signs or symptoms of stroke, and 33.6% knew how to call the emergency services. Notably, 25.2% of the participants had completed a college education. 8 In a recent study composed of a population of high school students from public schools in the northeastern region of Brazil, the results were virtually the same: only 10.0% of the students knew how to ideally act in a stroke situation, and 80.0% did not have the minimum knowledge of how to act in a stroke situation. 10 This deplorable  As for the older population, a study with a sample of 200 elderly Egyptians already known to have hypertension showed that more than half of them had inadequate knowledge about stroke, although almost a quarter of them had a history of stroke. 22 In contrast, a study conducted with the European population showed that the older population can recognize the signs and symptoms of stroke. 23 This suggests that the reason for the lower knowledge of the older adults who participated in our study is the lower educational level of this population.
Notably, participants with two or more comorbidities asso-  presence of comorbidities, increased access to health services, and knowledge about stroke.

CONCLUSION
Patients on dialysis have an increased risk of stroke compared with the general population; however, knowledge about this condition is frequently insufficient, particularly among female and older people.